Transcript hints at future PMD guidance

MECHANICSBURG, Pa. - The Pennsylvania Association of Medical Equipment Suppliers (PAMS) released last week a transcript of a recent seminar session with Dr. Paul Hughes that sheds new light on CMS's initial order requirement for power mobility devices. On Aug. 8, Hughes, the medical director for jurisdictions A and B, addressed about 100 attendees at a PAMS-sponsored seminar on documentation requirements for PMDs. PAMS developed the transcript in the weeks following the seminar. Even though Hughes and the other medical directors have reviewed the transcript, providers shouldn't consider it formal guidance, said Georgie Blackburn, a former PAMS president who sits on the Jurisdiction A/B Advisory Council. The medical directors plan to publish a FAQ based on the transcript, she said. Questions and answers from the session: Q: Must there always be two separate pieces of paper in an audit for power mobility devices: the face-to-face order and the detailed product description? A: Yes, the seven-element order specified in the Medicare Modernization Act and the detailed product description (DPD) must always be two separate pieces of paper. The seven-element order is a document that is written by the physician after completion of the face-to-face examination. The DPD is a document that is prepared by the supplier and sent to the physician after the supplier receives the seven-element order and the report of the face-to-face examination from the physician. Some suppliers refer to a prescription, given at the time of the initial office visit for a mobility evaluation, as the "face-to-face order." This prescription seems based on the concept of the "dispensing order" that is applicable to other DME items. For PMDs, a dispensing order is not applicable based upon the statutory requirements for the seven-element order. Q: May a supplier format the seven-element initial order upon receipt of a verbal order for a PMD and have the physician sign and date it? A: No, A supplier cannot draft a form to have the physician date and sign. The physician must write, sign and date the seven-element order. The supplier can draft instructions about the requirements for the order to help educate the physician. However, suppliers cannot complete the information required in the order. Q: A physician writes an order for "power wheelchair" but the client only qualifies for a scooter. Does the supplier need to get a new order for the scooter or will the home assessment and detailed product description substantiate why the patient received a scooter? A: Yes, in the scenario described, the supplier would need to obtain a new seven-element order from the physician. Because the supplier is providing an item that meets Medicare coverage criteria (i.e., a POV), the seven-element order must address this item in order for the item to be covered. In the scenario described, if the seven-element order were more general (e.g., "power mobility device"), then a new order would not be required, and the detailed product description would be sufficient to indicate physician agreement with a POV. Given a different scenario in which the seven-element order indicated a POV and this met the coverage criteria, a new order would not be required if the supplier provided a power wheelchair. In that scenario, the supplier must bill for the power wheelchair using the "upgrade" instructions. Q: A client is prescribed a new power wheelchair to replace his existing chair, which is 8 years old. It is impossible to repair the old unit for less than 50% of the replacement allowable for a new chair. Assuming the repairs carry a limited warranty, would the patient only qualify for repairs or would the 5-year useful lifetime apply? A: If a chair has reached its 5-year life expectancy, the chair can be replaced. However, if a chair reaches its 5-year life expectancy, is in good working order, and meets the beneficiary's medical needs, it should not automatically be replaced. Q: A scooter has been ordered for a client, but does not qualify because of accessibility issues inside the home. The patient is told by the supplier that she does not qualify, but the client calls Medicare and they tell her they will pay for outside use. What should a supplier do when a client is told wrong information? A: If a supplier or beneficiary is given inaccurate information from an inquiry, I recommend informing the appropriate management at the MAC. Q: What documentation will satisfy a home assessment for a manual wheelchair? A: Manual mobility home evaluations may be performed in any number of ways, via an on-site visit, indirectly in consultation with the beneficiary or their family, etc. Suppliers should maintain detailed records of that evaluation. Documentation should address ability to negotiate hallways, access rooms, etc. Q: Does TriCenturion have plans to educate physicians on what needs to be documented in the medical record and how? A: We have produced a number of items that discuss the documentation of the face-to-face evaluation, including an extensive section in the LCD. All of this material is made available to the Part B contractors, should they desire to use it. Traditionally, the MACs have also had some contact with medical associations for educational purposes. That being said, our primary responsibility is to educate suppliers. Ultimately, it is the provider's responsibility to educate their referral sources on coverage criteria and policies. There is no mechanism to have TriCenturion assist with the training. Q: Do you foresee audits increasing in Region A and B for increased usage of specific products? A: There has been no overall increase in the number of audits planned for specific products in Regions A or B by TriCenturion. However, as there are more auditing bodies, such as Recovery Audit Contractors and CERT, this would naturally increase the total number of audits. Q: Since the LCD is the basis for coverage and documentation, what importance should the providers put on LCD Training? A: Suppliers should be thoroughly familiar with the LCD, especially indications and limitations of coverage and documentation requirements. In addition, the related policy article provides important information about applicable statutory coverage criteria as well as coding guidelines. Q: For repairs, may travel time be charged using the A9900 procedure code for DME supply or A9270 non-covered service? A: Travel time is included in the reimbursement of parts and labor and may not be paid separately. If a supplier chooses to bill separately, code A9901 (DME delivery, set-up, and/or dispensing service component of another HCPCS code) must be used. This code is auto-denied as a CO denial. HCPCS Code A9270 must not be used. Q: Is a re-manufactured part with a warranty from the manufacturer considered new or used equipment? A: A re-manufactured part with a warranty is considered used. It should be billed using the appropriate modifier, UE. Q: How is a product replaced prior to the 5-year life expectancy? A: The replacement of a product before the 5-year life expectancy can only be done if the item is irreparably damaged, for example, by a natural disaster such as fire, flood, etc. Replacement due to wear and tear before the 5-year lifetime is not covered. Refer to the September 2003 articles for additional information. Q: If a new PMD is needed after 5 years of use, what documentation must be obtained? Must we start the complete process or just obtain a new order? A: All new PMD requirements must be met. Many new products are available, the codes have changed, and a patient's functional status must be assessed through a face-to-face evaluation in order to establish need. Q: If Dr. "A" performs a face-to-face assessment and orders a PT/OT evaluation and the PT/OT evaluation is sent back to Dr. A for concurrence but Dr. A is on vacation for two weeks, must we wait for Dr. A to return, or may another physician within the practice sign for the prescribing physician? A: If a doctor involved in a practice is on vacation, another doctor within the practice can sign the OT/PT assessment; however, there should be a notation in the patient chart indicating why a different physician is completing the info rather than the prescribing physician. Q: Do the Medicare Advantage plans have to follow Medicare guidelines? A: Medicare Advantage plans must follow the LCD as far as the minimum they must cover. They may offer more coverage than traditional Part B, but not less. As far as I know, NCDs are binding on them. Q: Some CERT audits are requesting initial documentation along with ongoing documentation for a continuous rental. Is this correct, as no documentation will be on file? A: Suppliers are expected to monitor the use of ongoing rental and supplies. If use is discontinued, no further billing is allowed. While the medical record, at the time of the initial order is key to demonstrating that the beneficiary meets coverage criteria, suppliers should monitor for any changes in the beneficiaries condition that may affect coverage of an item. Obviously, any changes in medical condition should be referred to a health care provider. In an audit, we would expect to see medical record information dating from the time of initial issue as well as information from the supplier describing any monitoring performed. In addition, some LCDs have specific requirements related to monitoring, documentation, recertification, etc. The supplier must comply with those specific requirements also. Q: Can the supplier facilitate the PT/OT evaluation when the physician faxes the request for PT/OT evaluation to the supplier? A: The physician must see the patient prior to writing an order for PMD. The physician should take care of the referral directly. If the supplier receives the PT/OT order, they may pass it along to the physician-selected therapist. The supplier should NOT choose the therapist. In addition, the supplier may not tell the PT/OT what to write in the evaluation. Q: Will Medicare pay for repairs to a piece of equipment that was obtained prior to the client being covered by Medicare? A: The beneficiary must meet the Medicare reimbursement criteria for the equipment to be repaired if Medicare did not purchase the item. If it was obtained prior to Medicare coverage or if another payer purchased the equipment, the supplier must obtain the required documentation to verify need and to determine if the item is covered or not covered by a warranty. Q: If a supplier does an "internal audit" and discovers there is missing patient chart information, may the physician draft a statement on letterhead or on a script pad and add it to the chart? A: No, information must be contained within the patient chart record and cannot be done as an addendum to the medical record at a later point in time due to an internal audit. It is inappropriate to amend or modify the medical record "after the fact."